Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

Hwang, Franchesca; Boardingham, Christine; Walther, Susanne; Jacob, Molly; Hidalgo, Andrea; Gandhi, Chirag D.; Mosenthal, Anne C.; Lamba, Sangeeta; Berlin, Ana

doi:10.1016/j.jpainsymman.2018.06.010

Cited by 7 publications

(4 citation statements)

References 12 publications

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“…The low utilization of hospice services is an opportunity both for families of deceased patients who could utilize bereavement services that come with the hospice, as well as for hospitals that are held accountable for inpatient mortality performance [ 22 , 23 ]. Establishment of clear goals of care is an important initiative that requires attention as disabling acute conditions, such as devastating stroke with severe deficits, are viewed as an unacceptable quality of life, worse than death [ 24 , 25 ]. There is a movement towards establishing clear goals of care documentation within 48 h of admission in safety-net medical centers to align patients’ values and goals in their medical care [ 26 ].…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients

et al. 2023

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Background Telestroke is an established telemedicine method of delivering emergency stroke care. However, not all neurological patients utilizing telestroke service require emergency interventions or transfer to a comprehensive stroke center. To develop an understanding of the appropriateness of inter-hospital neurological transfers utilizing the telemedicine, our study aimed to assess the differences in outcomes of inter-hospital transfers utilizing the service in relation to the need for neurological interventions. Methods The pragmatic, retrospective analysis included 181 consecutive patients, who were emergently transferred from telestroke-affiliated regional medical centers between October 3, 2021, and May 3, 2022. In this exploratory study investigating the outcomes of telestroke-referred patients, patients receiving interventions were compared to those that did not following transfer to our tertiary center. Neurological interventions included mechanical thrombectomy (MT) and/or tissue plasminogen activator (tPA), craniectomy, electroencephalography (EEG), or external ventricular drain (EVD). Transfer mortality rate, discharge functional status defined by modified Rankin scale (mRS), neurological status defined by National Institutes of Health Stroke Scale (NIHSS), 30-day unpreventable readmission rate, 90-day clinical major adverse cardiovascular events (MACE), and 90-day mRS, and NIHSS were studied. We used χ 2 or Fisher exact tests to evaluate the association between the intervention and categorical or dichotomous variables. Continuous or ordinal measures were compared using Wilcoxon rank-sum tests. All tests of statistical significance were considered to be significant at P < 0.05. Results Among the 181 transferred patients, 114 (63%) received neuro-intervention and 67 (37%) did not. The death rate during the index admission was not statistically significant between the intervention and non-intervention groups (P = 0.196). The discharge NIHSS and mRS were worse in the intervention compared to the non-intervention (P < 0.05 each, respectively). The 90-day mortality and cardiovascular event rates were similar between intervention and non-intervention groups (P > 0.05 each, respectively). The 30-day readmission rates were also similar between the two groups (14% intervention vs. 13.4% non-intervention, P = 0.910). The 90-day mRS were not significantly different between intervention and non-intervention groups (median 3 (IQR: 1 - 6) vs. 2 (IQR: 0 - 6), P = 0.109). However, 90-day NIHSS was worse in the intervention compared to non-intervention group (median 2 (IQR: 0 - 11) vs. 0 (IQR: 0 - 3), P = 0.004). Conclusions Telestroke is a valuable resource that expedites emergent neurological care via referral to a stroke center. However, not all transferred patients benefit from the transfer process. Future multicenter studies are warranted to study the effects or appropriateness of ...

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Section: Discussionmentioning

confidence: 99%

Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients

et al. 2023

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“…Many CPGs failed to identify and describe the potential facilitators, barriers and advice or tools on how the recommendations can be put into practice. This may be one of the reasons why clinical implementation is not as effective as it could be (9,35). To address this issue, we find that implementation science approaches are feasible, and a quality improvement intervention that includes online educational videos, mobile health technology, simplified versions of the guidelines manual, audits and feedback, is recommended to improve the CPG adherence of medical staff and patients, user awareness and CPG uptake (36)(37)(38)(39).…”

Section: Discussionmentioning

confidence: 99%

Quality appraisal of clinical practice guidelines for the management of Dysphagia after acute stroke

Gao,

Liu,

Han

et al. 2023

Front. Neurol.

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ObjectivesDysphagia is a common complication in stroke patients, widely affecting recovery and quality of life after stroke. The objective of this systematic review is to identify the gaps that between evidence and practice by critically assessing the quality of clinical practice guidelines (CPGs) for management of dysphagia in stroke.MethodsWe systematically searched academic databases and guideline repositories between January 1, 2014, and August 1, 2023. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used by two authors to independently assess CPG quality.ResultsIn a total of 14 CPGs included, we identified that three CPGs obtained a final evaluation of “high quality,” nine CPGs achieved “moderate quality” and two CPGs received “low quality.” The domain of “scope and purpose” achieved the highest mean score (91.1%) and the highest median (IQR) of 91.7% (86.1, 94.4%), while the domain of “applicability” received the lowest mean score (55.8%) and the lowest median (IQR) of 55.4% (43.2, 75.5%).ConclusionThe CPG development group should pay more attention to improving the methodological quality according to the AGREE II instrument, especially in the domain of “applicability” and “stakeholder involvement;” and each item should be refined as much as possible.

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“…Given the high hospital mortality of this patient group and the difficulty in accurate and consistent prediction of recovery early on, PCC may be appropriate to help patients set goals of care regarding interventions during the hospitalization (26)(27)(28)(29)(30). Evidence from the cancer literature suggests that having goals of care conversations early may help patients avoid the unwanted use of aggressive interventions and suffering at end-of-life (31)(32)(33)(34). Although early goals of care conversations are optimal, approximately 25% of PCC occurred on or after hospital day 7 in this patient population suggesting the potential need for earlier PCC to set goals of care with patients suffering severe stroke.…”

Section: Discussionmentioning

confidence: 99%

Palliative and End-of-Life Care After Severe Stroke

Comer¹,

Williams²,

Bartlett³

et al. 2022

Journal of Pain and Symptom Management

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Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

Abstract: We effectively increased documented GOC discussions before feeding gastrostomy tube placement among stroke patients. Systems-based tools and education will enhance this upstream trigger model to ensure early PC for stroke patients.

Cited by 7 publications

References 12 publications

Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients

Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients

Quality appraisal of clinical practice guidelines for the management of Dysphagia after acute stroke

Palliative and End-of-Life Care After Severe Stroke

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